Knowledge, attitudes, and practices related to COVID‐19 infection, related behavior, antibiotics usage, and resistance among Syrian population: A cross‐sectional study

Abstract Background and Aims Antibiotic resistance is seen as a worldwide health risk as a result of the overuse of antibiotics. Many countries noted that antibiotic usage was high during the COVID‐19 pandemic. The purpose of this study is to evaluate Syrians' knowledge, attitudes, and practice about the use of antibiotics and antibiotic resistance during the COVID‐19 epidemic. Methods A cross‐sectional study was conducted using an online questionnaire to collect the data from the Syrian population from February 5 to March 4, 2022. Syrians 18 years or older all over the world were able to participate in this study. A convenience snowball sampling method was used. SPSS version 20.0 was used to analyze the data. To examine the results, binominal logistic regression was used. Statistical significance was defined as a p < 0.05. Results Out of 2406 respondents, 60.2% knew that transmission of COVID‐19 could occur even if the patient has not developed any symptoms, and 91.6% were able to recognize the main clinical symptoms of COVID‐19. There was a statistically significant difference between male and female knowledge of COVID‐19 (p = 0.002), with males having 3.78 ± 2.1 (2.7–3.87) and females scoring 3.93 ± 2.3 (3.7–4.1). Newly graduated students have more knowledge of COVID‐19 than other subtypes of Job (p = 0.0001), and those with medical practice are more knowledgeable than those without (p = 0.0001). Only 16.6% answered that taking antibiotics would not speed up the recovery from all the infections. 65.3% answered correctly that misuse of antibiotics could cause antibiotic resistance. Conclusion Our study concluded that the Syrian population demonstrated good knowledge of COVID‐19 and moderate acceptance of the new norm. Knowledge regarding antibiotic use and resistance and practice of preventive measures was poor, which can encourage the health authorities to develop community education programs to increase public awareness of the usage of antibiotics and safety protocols during the COVID‐19 pandemic.


| INTRODUCTION
Coronavirus disease is a pathogenic viral infection brought on by the highly contagious SARS-CoV-2 virus, which was first discovered in Wuhan, the city of Hubei, China, in 2019. 1,2 SARS-CoV-2 is one of the coronaviruses; like other human coronaviruses, it has a singlestranded, positive-sense RNA genome and infects people by binding to the ACE2 receptor on the surface of their cells. 3,4 The COVID-19 virus is spread through infected people's droplets in the air. 5 The WHO received reports of a total of 6.09 million fatalities and 472.8 million confirmed cases up through March 2022. 6 In Syria, the number of confirmed cases and deaths were 55,595 and 3000, respectively. 6,7 The clinical signs and symptoms of COVID-19 might vary from an asymptomatic infection to a serious sickness needing hospitalization and oxygen support. 8 Patients with mild to moderate COVID-19 might experience fever, cough, sore throat, diarrhea, fatigue, fatigue, headache, muscle or joint pain, and loss of smell and taste. 9 At first, the treatment was limited to symptomatic and supportive measures. In 2021, therapeutic medications, including antiviral (e.g., remdesivir, Paxolvid and Molnupiravir) and supporting agents (corticosteroids, IL-6 antagonists), became available. 10,11 Anti-SARS-CoV-2 monoclonal antibodies (Bamlanivimab plus etesevimab, casirivimab plus imdevimab, and sotrovimab) have been authorized for the treatment of mild to moderate COVID-19 cases that have not yet required hospitalization but are at a high risk of developing into severe illness and/or inpatient care. 12 Antibiotics have been crucial in treating and controlling infectious illnesses since their discovery and have helped save countless lives. 13 However, in general practice, antibiotic misuse has led to difficulty in treating common infections, due to antibiotic-resistant bacteria that take longer to resolve and increase the burden on health care systems. 14,15 It is anticipated that this issue will worsen in developing nations where infectious illness is common, there is little access to healthcare, and regulations are weak. 13 In a cross-sectional study in Syria, 87% of pharmacies agreed to sell antibiotics without prescription. 16 Another study in Syria revealed that 85% of people used antibiotics within 4 weeks; only 43% of them were prescribed the antibiotic by a physician, while 57% used an old prescription or nonmedical advice to get the antibiotic. 17 This phenomenon can be attributed to poverty, low socioeconomic status, lack of health awareness, and limited health resources, especially after the war. 18,19 According to a Malaysian study, in the early stages of the COVID-19 epidemic, antibiotic use was not very common; only 17.1% of people used antibiotics, with 5.5% of patients receiving two or more antibiotic kinds 20 In 2021, 78% of COVID patients used systemic antibiotics other than macrolides; 72% used beta-lactams, 13% used quinolones, and 2.2% used linezolid. 21,22 During the COVID-19 pandemic in Syria, there was a significant increase in using antibiotics as well. 19 The knowledge, attitudes, and practices (KAP) of the public regarding the COVID-19 pandemic are essential. Therefore, researchers from Malaysia and Ethiopia investigated and found that the early phase of the pandemic was largely favorable. 23,24 KAP surveys may be used to find out additional information that will aid in the development of public education materials and to discover knowledge gaps, behavioral trends, or cultural attitudes. 23  We gathered the data we needed from the respondents using the convenience and snowball approaches. Several social media platforms, including Facebook, WhatsApp, Twitter, and Telegram, were used by the data gathering respondents, to publish the questionnaire to obtain a large sample. The sample size was estimated using Calculator.net, available at "https://www.calculator.net/sample-sizecalculator.html." The United Nations estimates that there will be roughly 18 million people living in Syria in 2019. 25 Then, using a 0.05 margin of error and a 95% confidence level, we ran a statistical power analysis to get the sample size, and the minimum sample size appeared to be 385. The used questionnaire was uploaded as Supporting Information.

| Measures
The 42 questions were separated into five parts on the questionnaire.
The first question was about the acceptance for participation and completing the survey; thus, we removed the people who refused to fill the questionnaire.

Knowledge of COVID-19 pandemic
The responses ranged from Correct, Incorrect, to Unsure (7 items).

Preventive measures during the COVID-19 pandemic
The replies were classified as "true" or "false" (10 items).

Knowledge of antibiotics use and resistance
The responses ranged from strongly Correct, Incorrect to Unsure (10 items).

Attitude toward new norms during the COVID-19 pandemic
There were a variety of replies, including strongly disagree, disagree, neutral, agree, and highly agree (7 items). The answers were re-categorized into "correct," "incorrect," and "unsure," including both domains of knowledge. Every correct response was given one point, while incorrect or unsure answers got zero. In the practice domain, each "yes" response was scored one point. Every strongly agreed or agreed response was given one point in the attitude domain. The following have been the minimum and maximum score ranges for each domain: COVID-19 (0-7), antibiotics (0-10), practice (0-10), and attitude (0-7). A pooled score of above 80% for each category reflects strong knowledge, adequate practice, and a good attitude.

| Statistical analysis
The SPSS version 20.0; IBM was employed to analyze the data and statistically significant considered at (p-value < 0.05). All of the SWED ET AL | 3 of 11 variables were analyzed in a descriptive form. The categorical results were reported as frequency and percentages, whereas means and standard deviations were used to report the continuous variables.
One-way analysis of variance (ANOVA) was conducted to determine if the KAP scores were different for sociodemographic characteristics. Data is presented as Mean± Standard Deviation (95% confidence interval: lower band-upper band). To determine the influence of baseline factors on the chance that Syrian participants had considerable knowledge about the COVID-19 pandemic and antibiotic usage and resistance, binominal logistic regression was used. To evaluate the association between KAP scores, a Pearson's item correlation was performed.

| Ethics
The Aleppo University and the Damascus Medical Research Ethics Committee provided their clearance. Participants were given a special URL to access the online survey on Google form. Participants were asked in the first page of the survey if they were able to complete the survey and were referred to the participant information page, which contained information about the study, before answering the survey, so the participation was optional, and the replies were kept private.
The volunteers were transferred to the online questionnaire after clicking "accept to participate." Each participant may take about 12 min to complete the questionnaire. All of the replies were stored in a secure online database.

| RESULTS
Two thousand four hundred and sixty-seven participants were invited to solve the online questionnaire on the google form. Out of which 18 persons refused to participate in the survey, and 43 were under 18. Thus, only 2406 were applicable for statistical analysis; 45.3% of the answers were received personally, and 54.7% were received through social media.
Most of the respondents' (71.9%) ages were between 18 and 29 years old, whereas only 6.9% were above 50. The majority of the respondents were females (67.2%), and 51.4% of them have finished or reached their university stage or above such as a master's or PhD 46% of total respondents were students, and 44.4% have a medical education background. Nonetheless, only 10.5% have confirmed being diagnosed earlier with chronic disease. Characteristics of respondents are described in Table 1.

| Knowledge of COVID-19
The understanding of COVID-19 among the respondents was evaluated using seven questions. The average score for knowledge was 5.22 (SD = 1.414, range 0-7). The total percentage of accurate responses was 74.5%. Most of the respondents could answer five out of seven questions correctly. However, only 60.2% knew that transmission of COVID-19 could occur even if the patient has not developed any symptoms, and 91.6% were able to recognize the main signs of COVID-19, but surprisingly 12.6% didn't realize that the COVID-19 pandemic is of viral origin as 1.5% answered "incorrect," and 10.1% were "not sure" about their answer (Table 2). Scores on the COVID-19 knowledge test varied by gender, age group, and educational level, the job, medical education, household income and chronic diseases using one way-ANOVA factor (  (Table 3).
Of the six predictor variables, only two were statistically significant: education level and the presence of medical education or practice (as shown in Table 4). University stage or above had 1.827 times higher odds to exhibit good knowledge toward COVID19 than primary or below the level of education. In addition, those with a medical practice or education were 2.83 times more likely than others to demonstrate accurate knowledge of COVID19.
3.2 | Knowledge of antibiotics use and resistance (n = 2406) Table 5 The respondents' mean score is 3.77 (SD = 2.19, range = 0-10), as the overall proportion of correct answers is 37.7%. The vast majority of respondents could not answer more than six correctly out of 10, indicating poor knowledge of antibiotics resistance (59.6%). When asked whether using antibiotics would hasten healing from all illnesses, just 16.6% said it wouldn't.
Remarkably, just 41% of participants realized that using antibiotics wouldn't prevent all illnesses, but 65.3% correctly identified how poor use of medicines would increase the development of antibiotic resistance ( Table 2). One-way ANOVA revealed differences in antibiotic resistance knowledge scores across genders, age groups, educational achievement, employment, medical training, family income, and chronic health conditions using one-way ANOVA (

| Practice of preventive measures
The  (Table 6).
We used a one-way ANOVA factor to compare the scores of different preventive practices against COVID19 across sexes, age category, educational attainment, employment, training in medicine, and family income, and chronic conditions (Table 3). Otherwise, a statistically significant difference was found between the age groups and practicing the preventive measures against COVID19, as shown in

| The correlation between the fourth scale
We identified a statistically significant, moderate positive correlation between knowledge of COVID19 scores and knowledge of antibiotics scores, practice scores and attitude scores (r = 0.41, p < 0.001), (r = 0.042, p = 0.039) and (r = 0.23, p < 0.001), respectively (Table 8).
We discovered a statistically significant, but weakly positive connection between antibiotic knowledge and attitude ratings (r = 0.25, p < 0.001) (Table 8). Furthermore, we found no statistically significant association, positive correlation between knowledge of antibiotics scores and practice scores (r = 0.16, p = 0.43), Table 7. However, we detected a statistically significant, weak positive correlation between practice scores and attitude scores (r = 0.51, p = 0.012) ( Table 8).

| DISCUSSION
Numerous KAP investigations on COVID-19 were carried out globally in an attempt to measure the efficacy of public health education systems. It is important to continuously observe the progressive COVID-19 situation to address the actual knowledge gap in the public and to develop more effective educational methods. In our study, we found that the general population of Syria has a Like the vast majority of KAP studies in many countries, 23,24,26,27 However, about 40% of respondents were uncertain or mistakenly believed that COVID-19 transmission only occurs through symptomatic persons as it is commonly known that COVID-19 is constantly spreading through asymptomatic carriers, and, 28

| Limitations
Initially, despite its cost-effectiveness and practicality, the crosssectional study design cannot prove causation. Moreover, through using uniform sample and achieving a rate of response of 99%, which is more than the usual response rate for organization questionnaire survey, this study's generalizability was enhanced. Because surveys were anonymous, there was no way to contact participants after they had finished their questionnaires to verify any unconventional answers. In addition, it is crucial to confirm the lack of generalizability SWED ET AL of our study findings toward those in the older age group, with lower educational background, and those without internet access who will be left out in this study.
With these limitations, several steps were taken to increase the study's dependability. To increase the internal validity of study results, for instance, use a validated instrument in addition to controlling for confounding factors in the final version and sample from a wide range of research places. A preconceived sample size calculations are also performed to make sure that the project is effective.

| CONCLUSION
Our study concluded that the Syrian population demonstrated good knowledge of COVID-19 and moderate acceptance of the new norm.
Knowledge regarding antibiotic use and resistance and practice of preventive measures was poor, which can encourage the health authorities to develop community education programs to increase public awareness of the usage of antibiotics and safety precautions during the COVID-19 epidemic.